Current Challenges

The Perfect Storm: Four Converging Healthcare Forces

The U.S. healthcare system is experiencing unprecedented regulatory convergence that's transforming how knee replacement decisions are made, measured, and governed. Four critical forces are creating both urgent challenges and massive opportunities for transparent, evidence-based prior authorization.

The Accountability Challenge

25% APU Reduction Penalty For non-compliance with PROMs collection
2027 Public Reporting CMS will publicly report improvement rates
50% Data Collection Minimum patient coverage required

Medicare's mandatory PROMs collection for TKA/THA shifts focus from volume to outcomes, with severe financial penalties for hospitals failing to demonstrate patient improvement.[6]

The Subjectivity Problem

High Physician Variation Significant disagreement on TKA indications
Elusive Surgical Readiness Guidelines remain unclear and subjective
Conflict Patient Decisions Uncertainty about surgical outcomes

Despite being one of the most common surgeries, TKA decisions remain "highly subjective and discretionary" with significant variation between orthopedic surgeons, rheumatologists, and primary care providers.[7]

The Transparency Requirement

6+ States with AI Laws Requiring physician oversight of AI decisions
Individual Data Requirement AI must use patient-specific, not group data
Explainable AI Mandate Transparent, reviewable decision-making

New state laws prohibit AI from making final prior authorization decisions without physician review, requiring transparent, explainable AI that bases decisions on individual patient data rather than population averages.[8]

The Evidence Gap Problem

30% TKAs Avoidable With structured conservative care
Weak Head-to-Head Evidence Conservative vs. surgical comparisons
Default TKA Becomes Default Choice due to evidence uncertainty

While structured conservative care (education, exercise, weight management) can avoid up to 30% of TKAs, the lack of robust head-to-head comparison evidence makes surgery the default choice. This evidence gap prevents optimal patient-treatment matching.[9]

PROMs Guidance

PRO-PM FAQ — PROMs Guidance (AAOS / CMS)

The PRO-PM Frequently Asked Questions fact sheet outlines PROMs collection, timing, and reporting expectations for hip and knee arthroplasty programs.[18] Providers implementing PROMs collection will find practical details on administration, follow-up timing, and reporting required by CMS.

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